Law Enforcement Security Clearance Form

Personal Information

Full Name Date of Birth Place of Birth Social Security Number Address Phone Number Email

Employment Details

Current Employer Position/Title Work Address Work Phone Supervisor Name

Background Information

Have you ever been arrested or convicted of a crime? No Yes If yes, please provide details Have you held a security clearance before? No Yes If yes, please provide level and issuing agency

References

Reference 1 - Name Reference 1 - Contact Information Reference 2 - Name Reference 2 - Contact Information

Additional Information

Additional Notes

Date Signature